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SHY BLADDERS AND SHY PEOPLE

The “shy bladder” syndrome is a form of social phobia, where affected people are unable to urinate in public restrooms because of intense anxiety. Another name for this condition is pareuresis. Very little was known about this condition and its treatment until relatively recently. At the Anxiety Disorders Association of America (ADAA) National Conference in March 1999, a seminar was held on the nature and treatment of the condition. For the first time, researchers discussed the results of their intervention programmes.

Social phobia is one of the Anxiety Disorders. There is some controversy in the literature about the term social phobia. In fact, there is now a movement afoot to change its name to social anxiety disorder, as some researchers feel that it is more an anxiety disorder than a pure social phobia. Changes may become apparent in the next Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association.

According to the DSMIV, social phobia is characterised by a marked and persistent fear of any situation where one has to mix socially in the company of unfamiliar people; or perform and then be scrutinised by others. The afflicted person fears embarrassing her/himself in public by displaying symptoms of anxiety (such as trembling or blushing). Exposure to such a situation invariably produces anxiety or even a panic attack.

The Book of Lists found public speaking topped the list of fears in the American population. Fear of death was only number six. This suggests that many people would rather die than give a public speech!

Much less common than public speaking is the fear generated by having to urinate in public toilets. Some men standing in front of a urinal find their urinary sphincter clamping shut. This is because of an involuntary locking of the sphincter musculature. These socially phobic men are embarrassed to stand for too long while others are waiting behind them, so they may forego urinating or avoid public toilets. In the case of women with pareuresis, the anxiety is more commonly about their urination being overheard. Hence they may switch on an automatic hairdryer or a tap to cover up the sound.

Social phobia is a psychiatric diagnosis that is frequently overlooked or underdiagnosed. Of all areas of performance anxiety involved in social phobia, pareuresis is perhaps least often diagnosed. For afflicted patients, it is the most shameful condition to have to discuss with a health care worker. In many cases, the patient’s spouse or partner is unaware of the condition. Quality of life may be severely impaired: in one instance described a holiday was not taken for 18 years. Anxiety about using toilets on airplanes during long distance flights can become complicated by avoiding fluids, subsequent dehydration or deep venous thrombosis.

Pareuresis is ten times more common in men. The obvious reason for this is that men are more often involved in situations where they are required to urinate in public. However, when women are afflicted, the condition appears to be more debilitating. The highest proportion of those affected appears to be aged between thirty and fifty years. The majority of sufferers do not know what caused their pareuresis. Interestingly, the nature of public toilets seems to determine the prevalence of pareuresis in different communities. In Europe and especially France, pareuresis is an infrequent manifestation of social phobia. This is because urinals are rare in public restrooms. Closed toilets are usually provided for men.

Besides raising awareness amongst clinicians and establishing better diagnosis practices, treatment is another way in which this low profile condition can be combated. There is very little in the literature about pareuresis in general; and even less about treatment. However, a group based in Baltimore has been developing a behavioural programme since 1997, with some success.

The format of the programme is a 3 day workshop which has been held in different centers in the USA. Day one explores personal stories of participants. The group then begins to list behavioral hierarchies. This entails ranking different situations in which one might have to urinate, from the least anxiety provoking (e.g. urinating in one’s own bathroom at home, alone), to the most (e.g. urinating at a public urinal with someone else less than a meter away). Cognitive messages are also explored as many people cannot understand how their bodies begin a new behaviour (urinating with others present) after so many years of avoidance behaviour. The cognitive message is that this is “impossible”. It appears that cognitive shifts follow behavioural changes.

Day two involves some psychoeducation about the condition and then a graduated exposure programme to treatment. Participants are divided into pairs (charmingly named “pee buddies” by the researchers!). The pairs undergo a series of exercises where urinating occurs initially in the least threatening of the graded exposure list and then progresses to more situation evoking higher anxiety. There is an optional outing thereafter.

Day three concludes the graduated exposure exercises and then addresses how improvement can be maintained once the programme is over. Follow up practice appears to be important. It allows progress to continue and maintains gains over time.

In half to two thirds of participants, the pareuresis improved significantly. While the treatment of pareuresis is still in its infancy, this behaviuoral programme with a weekend format appears to be highly efficient. Key issues are the safety of the environment, building trust and the practice sessions.

Further research is needed to establish more accurate epidemiological measures, the impact of psychopharmacological agents on outcome (initial results seem to indicate that the SSRIs are helpful) and a cognitive slant on the behavioural programme. Longer-term prognosis has yet to be studied. There is no doubt, however, that researchers are focussing more and more on previously neglected anxiety disorders and that important findings are forthcoming.